Ludewig PM, Saini G, Hellem A, et al.

Changing our Diagnostic Paradigm Part II:

Movement System Diagnostic Classification. IJSPT. 2022;17(1):7-17.

Invited Clinical Commentary

Changing our Diagnostic Paradigm Part II: Movement System

Diagnostic Classification
a
Paula M Ludewig, PT, PhD, FAPTA 1 , Gaura Saini, PT 2, Aaron Hellem, PT, OCS, SCS, CSCS 1, Emily K Kahnert, PT, CCTT 3,
S Cyrus Rezvanifar, PhD 1, Jonathan P Braman, MD, MHA 4, Justin L Staker, PT, PhD, OCS, SCS 1
1Department of Rehabilitation Medicine, University of Minnesota Divisions of Physical Therapy & Rehabilitation Science, 2 Department of
Rehabilitation Medicine, University of Minnesota Division of Rehabilitation Science, 3 Department of Rehabilitation Medicine, University of Minnesota
Division of Rehabilitation Science; Orofacial Pain & Dental Sleep Medicine Clinic, University of Minnesota School of Dentistry, 4 Department of
Orthopaedic Surgery, University of Minnesota
Keywords: Movement system, pathokinesiology, pathoanatomy, shoulder
https://doi.org/10.26603/001c.30177

International Journal of Sports Physical Therapy

Vol. 17, Issue 1, 2022

Diagnostic classification is a foundational underpinning of providing care of the highest

quality and value. Diagnosis is pattern recognition that can result in categories of
conditions that ideally direct treatment. While pathoanatomic diagnoses are common and
traditional in orthopaedic practice, they often are limited with regard to directing best
practice physical therapy intervention. Replacement of pathoanatomic labels with
non-specific regional pain labels has been proposed, and occurs frequently in clinical
practice. For example non-specific low back pain or shoulder pain of unknown origin.
These labels avoid some disadvantages of tissue specific pathoanatomic labels, but are
not specific enough to direct treatment. A previously introduced movement system
diagnostic framework is proposed and updated with application to shoulder conditions.
This framework has potential for broad development and application across
musculoskeletal physical therapist practice. Movement system diagnostic classification
can advance and streamline practice if considered while recognizing the inherent
movement variability across individuals.

INTRODUCTION “the basic advantage of, and therefore rationale for,

In 2013, the American Physical Therapy Association
adopted the vision of “Transforming society by optimizing
movement to improve the human experience”.1 Associated
guiding principle language (pg. 1) includes “As independent
practitioners, doctors of physical therapy in clinical practice
will embrace best practice standards in examination, di-
agnosis/classification, intervention, and outcome measure-
ment.” “The physical therapy profession will demonstrate
the value of collaboration with other health care providers,
consumers, community organizations, and other disciplines
to solve the health-related challenges that society faces”.1
In this collaborative spirit, we must ask ourselves how do
we continue to advance the “best practice standards in ex-
amination, diagnosis/classification, intervention, and out-
come measurement”? Diagnostic classification is a founda-
tional underpinning of providing care of the highest quality
and value. As noted by Zimny in 2004 (pg. 106),2
classifying and diagnosing clinical problems in medi-
cine is to impose order on information from clinical
and laboratory findings that otherwise would remain
chaotic and unconnected. Classification and labeling
allow generalizations to be made that can then be used
to identify and treat similar problems so that each new
patient need not be treated de novo. Furthermore, di-
agnostic classification and labeling provide a structure
which allows clinicians to better predict and compare
outcomes of interventions for given categories of dis-
ease.”2
Despite the critical importance of diagnostic classifica-
tion across all of medicine, many pragmatic challenges ex-
ist. Zimny2 succinctly summarized primary concerns to in-
clude subjectivity in classification, the lack of mutually
exclusive and jointly exhaustive categorizations as relates
to clinical problems, and difficulty determining the appro-
priate level of specificity at which to classify. Despite our
100-year history as a profession, and extensive existing di-
agnostic labels in medicine, limited diagnostic consistency

a Corresponding Author:
Paula M Ludewig, PT, PhD, FAPTA
University of Minnesota Divisions of Physical Therapy & Rehabilitation Science
426 Church St SE, Minneapolis, MN 55112
ludew001@umn.edu
 Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification
is present in orthopaedic physical therapy.3 An ongoing
concern with a lack of diagnostic consistency or specificity
in the profession, and in fact across medicine itself, is vari-
ation in practice.4,5 Practice variation limits our ability to
define, educate, and provide best practice.
In a 2017 International Journal of Sports Physical Ther-
apy article, we introduced a broad framework for shoulder
movement system diagnostic classification as an alternative
to traditional pathoanatomic diagnoses.6 The purpose of
this current manuscript is to provide an update and further
illustration of the framework.
MOVING AWAY FROM PATHOANATOMIC LABELS
Since 2017, there have been growing calls from varied per-
spectives to move away from medicine’s reliance on
pathoanatomic labels.7,8 Rationale for such a change in-
cludes considerations of lack of connection between pres-
ence of tissue pathology and symptoms such as pain,9 in-
creased understanding of pain processing,10 the presence
of comorbid tissue pathologies,11 the high cost and uncer-
tain value of diagnostic imaging,9 the limited value of clin-
ical “special tests”,12 and the influence a diagnostic label
may have on patient expected outcomes and perceived need
for invasive treatments such as surgery.8,13,14 A recent in-
vestigation of over 100 patients with unilateral shoulder
pain demonstrated a nearly equivalent prevalence of tissue
pathology on the asymptomatic versus the symptomatic
side.9 Importantly however, tissue pathology should not be
uniformly dismissed either. More advanced pathology such
as glenohumeral arthritis or full thickness rotator cuff tears
were significantly more prevalent on the symptomatic side
as compared to the asymptomatic side.9
In addition to the above mentioned limitations to
pathoanatomic diagnostic labels, it is important to keep
in mind that tissue pathology is the “end stage” of mul-
tifactorial cumulative trauma injuries common to muscu-
loskeletal conditions15 (Figure 1). There is evidence that
malalignment16 or specific repetitive movement joint load-
ing patterns17 can be risk factors for development of mus-
culoskeletal disease such as osteoarthritis. If we strive as
health care providers to provide risk mitigation interven-
tions aiming to prevent pain and pathology, we need to be
able to intervene before excess tissue stress or strain leads
to tissue pathology. This approach has been used success-
fully with programs designed to reduce dynamic knee val-
gus to prevent anterior cruciate ligament injury, as an ex-
ample.18
In musculoskeletal health and disease, numerous diag-
nostic labels exist and are employed in clinical practice
guidelines, as well as coding and reimbursement. There are
advocates of moving from pathoanatomic labels to non-
specific regional labels as preferred terms.8,19 Examples in-
clude diagnostic labels for non-specific low-back pain or
shoulder pain of unknown origin.19 We agree with previous
advocates8,14,19 that these non-specific labels may reduce
unnecessary surgery or over reliance on expensive imaging
modalities in cases where specific tissue pathologies are be-
ing labeled that do not relate to a patient’s symptoms or
function.14 However, the lack of specificity of regional pain
labels brings us back to the concern of how do such labels
International Journal of Sports Physical Therapy
Figure 1. Progression of cumulative trauma
disorders from repetitive loading that exceeds tissue
fitness,15 to pain and tissue pathology.
Diagnoses occurring only after the presence of pain or tissue pathology are in-
herently unable to mitigate early movement related risk factors.
go beyond a restating of the patient’s chief complaint and
move toward directing best practice? For example, recent
changes in Medicare approved ICD-10 codes occurred in an
attempt to require increased specificity regarding low back
pain diagnoses.20
MOVEMENT SYSTEM DIAGNOSTIC
CLASSIFICATION
Advocacy has occurred for the use and development of
movement system diagnostic labels and classifications as
well.21,22 Several labels already exist within traditional
musculoskeletal diagnoses that are compatible with move-
ment system labels, for example - instability. A movement
system diagnostic classification identifies characteristic
movement system impairments, activity, or functional lim-
itations that presumably cause, contribute to, or are caused
by the patient’s pain or dysfunction. This classification
leads directly to movement focused interventions (treating
these impairments or functional limitations). Physical ther-
apist practice already focuses on treating movement im-
pairments. Diagnostic classifications within the movement
system can subsequently further direct treatment. Figure 2
demonstrates how for the same patient problem, a physi-
cal therapist will focus on a movement system classifica-
tion to maximize functional outcome for a patient, while
an orthopaedic surgeon will focus on tissue status. Both
professionals need to understand the other’s area of ex-
pertise (pathoanatomy versus pathokinesiology), and how
these components interact to impact function and dysfunc-
tion for the client.6
It is important to recognize that a diagnostic classifica-
tion within the movement system would not and should
not require new physical therapy “profession specific” diag-
nostic labels used and understood only by physical thera-
pists.23,24 Rather the classification is specific to the health
of a system – the movement system, rather than specific
to the health of musculoskeletal tissue (e.g. rotator cuff).
 Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification

Figure 2. Depiction of similarities and differences in how an orthopaedic surgeon and a physical therapist may
evaluate and treat the same client.
Each provider’s evaluation will focus on the respective area they are able to treat (surgeon - pathoanatomy; physical therapist – pathokinesiology). Both professions are inter-
ested in the presence or absence of various tissue pathologies, but from a differing perspective. Both professions are directed toward assisting the client to obtain the best pos-
sible functional outcome.

The American Physical Therapy Association (APTA) has en-
dorsed the following criteria for use with a movement sys-
tem diagnostic classification25: 1) Use recognized move-
ment-related terms to describe the condition or syndrome
of the movement system. 2) Include, if deemed necessary,
the name of the pathology, disease, disorder, anatomical or
physiological terms, and stage of recovery associated with
the diagnosis. 3) Be as succinct and direct as possible to im-
prove clinical usefulness. 4) Strive for movement system di-
agnoses that span all populations, health conditions, and
the lifespan. Whenever possible, use similar movement-re-
lated terms to describe similar movements, regardless of
pathology or other characteristics of the patient or client.25
Historically for atraumatic shoulder pain, the most com-
mon diagnoses have been shoulder instability, frozen
shoulder/adhesive capsulitis, and shoulder impingement/
rotator cuff disease.6 These conditions can be easily
adapted to a movement system framework (Figure 3) by
reframing diagnoses broadly as hypermobility/stability
deficit, hypomobility/mobility deficit, or aberrant motion/
movement coordination deficit. This classification is not
highly specific, but advances specificity beyond regional
pain categorizations such as subacromial pain syndrome or
shoulder pain of unknown origin. These general movement
categories could be easily understood by other health pro-
fessionals and patients alike, while also beginning to direct
physical therapy interventions, since changing movement
patterns can alter loading profiles.26,27 Physical therapists
can manipulate environmental, individual, or task con-
straints to allow the patient to attain desired movement
patterns through the principles of motor learning.28
Even at this stage of rethinking a classification (three
main groups), there are a number of advantages to the
movement system based framework, as noted in our previ-
ous manuscript.6 First, “the overall treatment goals are de-
rived directly from the diagnostic category: improve func-
tional stability in clients in the hypermobility category;
improve functional mobility in clients in the hypomobility
category; and improve functional movement coordination
or balance of mobility and stability in clients in the aberrant
motion category. We would not apply treatments to gain
mobility with a client with hypermobility and so forth. This
framework further prioritizes the movement in the classi-
fication system, and also in the diagnostic process”.6(p888)
A movement examination assessing both quality and quan-
tity of movement follows directly after the patient history
(Appendix A). Special tests to identify tissue pathology are
best used more selectively to potentially modify the inter-
vention approach and inform prognosis and/or coordina-
tion of care after identifying a movement classification. Be-
cause the movement system is the focus of the diagnosis,
there are no issues with scope of practice,29,30 and no over
reliance on costly medical imaging. There is also not an as-
sumed connection to immediate surgical intervention (e.g.
tissue torn and not repairable without surgery), as opposed
to an evidence-based consideration of all factors with surgi-
cal referral when needed.
INCREASED SPECIFICITY
Moving to a greater level of specificity in shoulder move-
ment classification is illustrated in Figure 4. For shoulder
conditions for example, based on the history (Appendix A),
a qualitative movement examination is performed that in-
cludes alignment and repeated shoulder movement assess-
ment. The serratus anterior inferior and trapezius muscles
play a critical role in both moving and stabilizing the
scapula, but have differential contributions in flexion ver-
sus abduction.31 Therefore, evaluation of arm elevation
into both flexion and abduction overhead reaching is rec-
ommended, along with an evaluation of the “problem”
movement as reported by the client history. The history and
movement examination provide the ability to formulate hy-
potheses regarding what movement impairments are con-
tributing to or resulting from the patient’s symptoms or
dysfunction. The remaining examination can subsequently

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 Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification

Figure 3. Three proposed broad classifications of shoulder pain following a movement system diagnostic
framework, after ruling out conditions not of shoulder origin.

Figure 4. Proposed classification of primary patterns of movement impairments.

Clients may present with shoulder pain of non-mechanical or non-shoulder origin, requiring alternate classification. Within those with symptoms or dysfunction of mechani-
cal origin, glenohumeral or scapulothoracic subtypes are distinguished. Further specificity is provided for the scapulothoracic subtypes. It is recognized that multiple move-
ment impairments may be present and the classification is based on the movement impairment pattern believed most relevant to the client’s presentation.

be directed to confirming/refuting these hypotheses, and
reducing reliance on special tests.
In our proposed framework, non-mechanical or unre-
lated causes (cervicogenic, cardiac conditions) of shoulder
pain are ruled out, and primary glenohumeral impairments
are distinguished from scapulothoracic impairments. Sub-
types of each primary movement impairment are then con-
sidered with the understanding that movement emerges as
a result of the interactions between individual, environ-
mental, and task constraints.28 From this primary move-
ment impairment pattern, we proceed with additional tests
and measures to determine primary movement system con-
tributors such as tissue flexibility, muscle force production,
coordination, etc. (Figures 5 and 6). Finally, we assess for
important pathoanatomic contributors, such as a tissue tear
or nerve injury. This framework of movement system di-
agnostic classification is presented for shoulder conditions,
however, a similar framework can be applied to an array
of musculoskeletal conditions. A proposed diagnostic clas-
sification for temporomandibular disorders is presented in
Figure 7. This classification integrates movement system
and pathoanatomic considerations. The flowchart uses ob-
jective exam results to classify a movement dysfunction as
mobility or coordination deficits with further refinement/
specificity of muscle vs. joint involvement. Additional test
results refine the pathoanatomic diagnosis according to the
criteria outlined in the Diagnostic Criteria for TMD.32 Of
note, this classification is inherently multidisciplinary,
based on accepted diagnostic classification in dental prac-
tice.32,33

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 Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification

Figure 5. Additional classification of potential movement impairment contributors to a condition, and

subsequent targeted treatment approaches that may follow.

Figure 6. Depiction of potential movement system impairments to be assessed following from identification of
primary movement pattern abnormalities.
These impairments if present would lead directly to treatment planning decisions.

With regard to the shoulder, Figure 4 presents common movement dysfunction in each of the three planes (sagittal
movement patterns recognized in a number of previously - scapular tilting; frontal - clavicle elevation or scapular
described classifications.34–37 These patterns are not typi- downward rotation; transverse - scapular internal rotation).
cally present in isolation. For instance, insufficient scapular Structuring movement patterns in such a way may stan-
upward rotation is often associated with glenohumeral hy- dardize the clinical evaluation process and the education of
permobility,38,39 and excess scapular internal rotation and new clinicians.37
insufficient scapular posterior tilt may occur in combina-
tion.40 A classification is not determined based on simply CASE EXAMPLE
the presence of an isolated movement impairment, but in-
stead on the collective history and physical examination,
A 22-year-old male presents with a chief complaint of right
including assistance or symptom relief tests34,41,42 as well
anterior shoulder joint pain specific to shoulder overhead
as pain provocation tests or movements. Clinical judgement
motions. Pain is easily provoked with unresisted arm eleva-
is used to assimilate the collective examination findings in
tion, but is of minimal severity (2/10 on a 0-10 pain scale)
determining which classification is most representative of
and does not persist after exacerbating movements are dis-
the client’s movement system dysfunction while incorpo-
continued. Thus he demonstrates a condition with low irri-
rating the environmental and personal factors unique to
tability. He reports aching pain in the joint without numb-
each patient. Figure 5 illustrates that from a movement
ness, tingling, radiating pain, or substantive weakness. He
classification, a clinician can further assess for the asso-
reports pain began after a feeling of excessive shoulder
ciated movement system impairments that would be the
“strain” while playing volleyball. Arm elevation into flexion
focus of a treatment intervention. These representations
is most painful, there is no pain at rest, and arm elevation
are not considered all-inclusive or complete, but provide
into abduction is not substantively painful. He is otherwise
an example of a framework for further investigation. For
an active, healthy individual with no confounding demo-
example, the proposed scapulothoracic patterns represent

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 Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification

Figure 7. Temporomandibular Disorder Sample Diagnostic Classification.

This classification uses objective exam results to determine movement dysfunction with further delineation of pathoanatomic conditions. MMO = Maximum mouth opening
measured in millimeters (mm); TMJ arthralgia = Joint pain; DDwoR = Disc Displacement without Reduction; DDwR = Disc Displacement with Reduction; TMJ OA = TMJ Os-
teoarthritis (including joint and disc degeneration conditions). Proposed by Kahnert EK integrated with Schiffman diagnostic criteria.32

graphics or co-morbid conditions. No red or yellow flags are

identified.
Qualitative and quantitative alignment and movement
assessment demonstrates reduced clavicle elevation and re-
duced scapular upward rotation with his arms relaxed at
his side. Cervical and thoracic posture are unremarkable. As
he elevates his arm into flexion, his scapula demonstrates
increased anterior tilt rather than expected posterior tilt43
(Figure 8). This individual’s posterior tilt first begins at ap-
proximately 90 degrees of arm flexion as determined visu-
ally, and shoulder pain is present in the mid to end range
of shoulder flexion. Flexion and abduction range of motion
are within normal limits but demonstrate reduced scapular Figure 8. Case example of an individual with
upward rotation throughout the range. A scapular assis- excessive scapular anterior tilt during shoulder
tance test44 with manual support to scapular posterior tilt flexion.
and upward rotation is positive during flexion. Repetitive The individual’s scapula anteriorly tilts during the lower half of elevation (A) and
motion results in slight increases in his aberrant scapular begins to posteriorly tilt around 90 degrees of elevation (B).

movement patterns.
Incorporation of surface electromyographic (EMG) as-
ilarly increasing along with anterior deltoid muscle activity
sessment into his evaluation demonstrates a substantial de-
for the first 70 degrees of flexion producing simultaneous
lay of his serratus anterior muscle activation as compared to
scapular posterior tilt and humeral flexion.
activation of the anterior deltoid when raising his arm into
Even without EMG of the muscle activation pattern, the
flexion (Figure 9, Participant A). This is consistent with the
movement examination allows us to streamline our physical
“reverse action” movement pattern demonstrated whereby
examination. We still must assess joint mobility (unremark-
unopposed anterior deltoid contraction results in anterior
able in his case) and overall muscle strength (within normal
rather than posterior tilt of the scapula as flexion is initi-
limits). However, integrating the movement exam and the
ated. Serratus anterior activation begins to noticeably in-
history allows us to more efficiently complete the physical
crease above 90 degrees humeral flexion corresponding to
exam. In this case we need to rule out long thoracic nerve
the onset of scapular posterior tilt. For comparison, Figure
palsy and can do so through basic manual muscle testing
9 Participant B depicts EMG from another individual who
of his serratus (within normal limits) which can be further
demonstrated typical scapular posterior tilting during
confirmed by surface EMG in this case.
shoulder flexion. Serratus anterior muscle activity was sim-
Based on our classification, a movement system diagno-

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 Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification

Figure 9. Root mean square processed EMG (300 ms time constant) collected on two individuals during
unresisted shoulder flexion.
Participant A shows delay in full activation of the serratus until later in the range of motion compared to Participant B. EMG is expressed as a percent of maximum voluntary
contraction. Participant A was classified with insufficient scapular posterior tilt while Participant B demonstrated a typical scapular posterior tilt pattern.

sis of insufficient scapular posterior tilt associated with co-
ordination/control deficit is provided. Therefore, his treat-
ment follows from his diagnosis and includes movement
training exercises to improve serratus anterior activation45
timing including wall slides46 and scapular protraction with
flexion movement training. Electromyographic biofeedback
could be helpful in accelerating motor learning to improve
serratus activation timing. Specific exercise or biofeedback
selection based on the individual’s history and physical
exam are examples of manipulating task and environmental
constraints to attain a desired change in motor behavior of
the movement system.
LIMITATIONS
Movement system classification is not without its limita-
tions. First, aberrant movement does not occur in isolation.
Rather, movement patterns emerge based on interactions
between the individual, environment, and task.28 Thus, it is
imperative that clinicians encourage the patient to demon-
strate their painful activities in a context similar to that
in which symptoms occur. Second, movement is inherently
variable occurring on the backdrop of individual biology,
anatomy, physiology, and task demands.15,47 Some vari-
ability is to be expected and can be assessed as part of the
movement system’s ability to adapt to the changing con-
straints present in daily life, for example eccentric versus
concentric loading.48–50 More research is needed to deter-
mine how to distinguish expected and potential beneficial
movement variation from movement variation that alters
tissue loading in detrimental ways. Third, there is potential
for misinterpretation of movement systems classification as
one “right way” to move. Education should be provided that
there is a range of acceptable movement variation. Finally,
symptom improvement as a result of interventions may not
be related to permanent biomechanical change.27 Effective
alterations in movement patterns will redistribute load to
reduce symptoms with the goal of allowing a full return to
previously aggravating activities. To achieve long-term bio-
mechanical changes, movement system training appears to
require task specificity.27
SUMMARY
Meeting our professional vision requires us to “take a seat
at the table” with regard to the development and refinement
of diagnostic classifications best able to direct practice,
maximize patient outcomes, and determine relative value
of services. All of these goals further relate to our ability
to produce effective clinical practice guidelines, educate fu-
ture professionals, and achieve the recognition deserved as
advanced practice providers. While effectiveness of physi-
cal therapy is well demonstrated for shoulder conditions,51
most outcomes do not demonstrate fully resolved symp-
toms or positive outcomes for all individuals.52 Continued
development and refinement of our diagnostic framework
is needed. Movement system diagnostic classification can
advance and streamline practice if considered while recog-
nizing the inherent movement variability across individu-
als. To transform society, we must transform, validate, and
translate a movement system diagnostic practice to “solve
the health related challenges that society faces”.
Submitted: October 31, 2021 CST, Accepted: November 28,
2021 CST

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 Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification
REFERENCES
1. American Physical Therapy Association. Vision
Statement for the Physical Therapy Profession.
Published online September 25, 2019. Accessed
November 8, 2021. https://www.apta.org/siteassets/p
dfs/policies/guiding-principles-to-achieve-the-visio
n.pdf
2. Zimny NJ. Diagnostic classification and
orthopaedic physical therapy practice: what we can
learn from medicine. J Orthop Sports Phys Ther.
2004;34(3):105-109. doi:10.2519/jospt.2004.34.3.105
3. Miller-Spoto M, Gombatto SP. Diagnostic labels
assigned to patients with orthopedic conditions and
the influence of the label on selection of
interventions: a qualitative study of orthopaedic
clinical specialists. Phys Ther. 2014;94(6):776-791. do
i:10.2522/ptj.20130244
4. Jewell DV, Moore JD, Goldstein MS. Delivering the
physical therapy value proposition: a call to action.
Phys Ther. 2013;93(1):104-114. doi:10.2522/ptj.20120
175
5. Committee on Quality of Health Care in America. The
Institute of Medicine. Crossing the Quality Chasm: A
New Health System for the 21st Century. National
Academies Press; 2001.
6. Ludewig PM, Kamonseki DH, Staker JL, Lawrence
RL, Camargo PR, Braman JP. Changing our diagnostic
paradigm: movement system diagnostic
classification. Int J Sports Phys Ther.
2017;12(6):884-893. doi:10.26603/ijspt20170884
7. Innocenti T, Ristori D, Miele S, Testa M. The
management of shoulder impingement and related
disorders: a systematic review on diagnostic accuracy
of physical tests and manual therapy efficacy. J Bodyw
Mov Ther. 2019;23(3):604-618. doi:10.1016/j.jbmt.201
8.08.002
8. Friedman DJ, Tulloh L, Khan KM. Peeling off
musculoskeletal labels: sticks and stones may break
my bones, but diagnostic labels can hamstring me
forever. Br J Sports Med. 2021;55(21):1184-1185. doi:1
0.1136/bjsports-2021-103998
9. Barreto RPG, Braman JP, Ludewig PM, Ribeiro LP,
Camargo PR. Bilateral magnetic resonance imaging
findings in individuals with unilateral shoulder pain. J
Shoulder Elbow Surg. 2019;28(9):1699-1706. doi:10.10
16/j.jse.2019.04.001
10. Moayedi M, Davis KD. Theories of pain: From
specificity to gate control. J Neurophysiol.
2013;109(1):5-12. doi:10.1152/jn.00457.2012
International Journal of Sports Physical Therapy
11. Vinson EN, Wittstein J, Garrigues GE, Taylor DC.
MRI of selected abnormalities at the anterior superior
aspect of the shoulder: potential pitfalls and subtle
diagnoses. Am J Roentgenol. 2012;199(3):534-545. do
i:10.2214/ajr.12.8789
12. Hegedus EJ, Goode AP, Cook CE, et al. Which
physical examination tests provide clinicians with the
most value when examining the shoulder? Update of
a systematic review with meta-analysis of individual
tests. Br J Sports Med. 2012;46(14):964-978. doi:10.11
36/bjsports-2012-091066
13. Nickel B, Barratt A, Copp T, Moynihan R,
McCaffery K. Words do matter: a systematic review on
how different terminology for the same condition
influences management preferences. BMJ Open.
2017;7(7):e014129. doi:10.1136/bmjopen-2016-01412
9
14. Zadro JR, O’Keeffe M, Ferreira GE, et al.
Diagnostic Labels for Rotator Cuff Disease Can
Increase People’s Perceived Need for Shoulder
Surgery: An Online Randomized Controlled
Experiment. J Orthop Sports Phys Ther.
2021;51(8):401-411. doi:10.2519/jospt.2021.10375
15. Lawrence RL, Ludewig PM, Ward SR. An
Integrated Approach to Musculoskeletal Performance,
Disease, and Recovery. Phys Ther. Published online
September 24, 2021. doi:10.1093/ptj/pzab225
16. Felson DT, Niu J, Gross KD, et al. Valgus
malalignment is a risk factor for lateral knee
osteoarthritis incidence and progression: findings
from the Multicenter Osteoarthritis Study and the
Osteoarthritis Initiative. Arthritis Rheumatism.
2013;65(2):355-362. doi:10.1002/art.37726
17. Bittersohl B, Benedikter C, Franz A, et al. Elite
rowers demonstrate consistent patterns of hip
cartilage damage compared with matched controls: A
T2* mapping study. Clin Orthop Rel Res.
2019;477(5):1007-1018. doi:10.1097/corr.0000000000
000576
18. Webster KE, Hewett TE. Meta-analysis of meta-
analyses of anterior cruciate ligament injury
reduction training programs. J Orthop Res.
2018;36(10):2696-2708. doi:10.1002/jor.24043
19. Schellingerhout JM, Verhagen AP, Thomas S, Koes
BW. Lack of uniformity in diagnostic labeling of
shoulder pain: time for a different approach. Manual
Therapy. 2008;13(6):478-483. doi:10.1016/j.math.200
8.04.005
 Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification
20. American Physical Therapy Association.
Homepage-News-Beginning Oct. 1: Stop Using this
ICD-10 Code for LBP. Published September 29, 2021.
Accessed November 8, 2021. https://www.apta.org/ne
ws/2021/09/29/icd-10-update
21. Sahrmann S. Defining our diagnostic labels will
help define our movement expertise and guide our
next 100 years. Phys Ther. 2021;101(1):pzaa196. doi:1
0.1093/ptj/pzaa196
22. Cools AM, Michener LA. Shoulder pain: can one
label satisfy everyone and everything? Br J Sports
Med. 2017;51:416-417.
23. Hedman LD, Gill-Body KM, Quinn L, et al. On
“Reflections on the Wisdom of Profession-Specific
Diagnostic Labels.” Jette AM. Phys Ther.
2021;101:pzab139. Phys Ther. Published online 2021.
doi:10.1093/ptj/pzab237
24. Jette AM. Reflections on the Wisdom of
Profession-Specific Diagnostic Labels. Phys Ther.
2021;101(6):pzab139. doi:10.1093/ptj/pzab139
25. American Physical Therapy Association. Board of
Directors Meeting Minutes. April 2017 26-29.
Published online April 2017. http://www.apta.org/BO
D/Meetings/Minutes/2017/4/26/
26. Kernozek T, Schiller M, Rutherford D, Smith A,
Durall C, Almonroeder TG. Real-time visual feedback
reduces patellofemoral joint forces during squatting
in individuals with patellofemoral pain. Clin Biomech.
2020;77:105050. doi:10.1016/j.clinbiomech.2020.1050
50
27. Willy RW, Willson JD, Clowers K, Baggaley M,
Murray N. The effects of body-borne loads and
cadence manipulation on patellofemoral and
tibiofemoral joint kinetics during running. J Biomech.
2016;49(16):4028-4033. doi:10.1016/j.jbiomech.201
6.10.043
28. Newell KM. Constraints on the Development of
Coordination. In: Wade MG, Whiting HTA, eds. Motor
Development in Children: Aspects of Coordination and
Control. Martinus Nijhoff; 1986:341-360.
29. Sahrmann SA. The human movement system: our
professional identity. Phys Ther.
2014;94(7):1034-1042. doi:10.2522/ptj.20130319
30. Ludewig PM, Lawrence RL, Braman JP. What’s in a
name? Using movement system diagnoses versus
pathoanatomic diagnoses. J Orthop Sports Phys Ther.
2013;43(5):280-283. doi:10.2519/jospt.2013.0104
31. Inman VT, Saunders JD, Abbott LC. Observations
on the function of the shoulder joint. JBJS.
1944;26(1):1-30.
International Journal of Sports Physical Therapy
32. Schiffman E, Ohrbach R, Truelove E, et al.
Diagnostic Criteria for Temporomandibular Disorders
(DC/TMD) for clinical and research applications:
recommendations of the international RDC/TMD
consortium network and orofacial pain special
interest group. J Oral Facial Pain Headache.
2014;28(1):6-27. doi:10.11607/jop.1151
33. Harrison AL, Thorp JN, Ritzline PD. A Proposed
Diagnostic Classification of Patients With
Temporomandibular Disorders: Implications for
Physical Therapists. J Orthop Sports Phys Ther.
2014;44(3):182-197. doi:10.2519/jospt.2014.4847
34. Caldwell C, Sahrmann S, Van Dillen L. Use of a
movement system impairment diagnosis for physical
therapy in the management of a patient with
shoulder pain. J Orthop Sports Phys Ther.
2007;37(9):551-563. doi:10.2519/jospt.2007.2283
35. Burkhart SS, Morgan CD, Kibler WB. The disabled
throwing shoulder: Spectrum of pathology part III:
The SICK scapula, scapular dyskinesis, the kinetic
chain, and rehabilitation. Arthroscopy.
2003;19(6):641-661. doi:10.1016/s0749-8063(03)0038
9-x
36. Uhl TL, Kibler WB, Gecewich B, Tripp BL.
Evaluation of clinical assessment methods for
scapular dyskinesis. Arthroscopy.
2009;25(11):1240-1248. doi:10.1016/j.arthro.2009.0
6.007
37. Joe Godges, DPT, OCS personal communication.
38. Paletta GA Jr, Warner JJP, Warren RF, Deutsch A,
Altchek DW. Shoulder kinematics with two-plane x-
ray evaluation in patients with anterior instability or
rotator cuff tearing. J Shoulder Elbow Surg.
1997;6(6):516-527. doi:10.1016/s1058-2746(97)9008
4-7
39. Ogston JB, Ludewig PM. Differences in
3-dimensional shoulder kinematics between persons
with multidirectional instability and asymptomatic
controls. Am J Sports Med. 2007;35(8):1361-1370. do
i:10.1177/0363546507300820
40. Seitz AL, McClure PW, Finucane S, Boardman ND
III, Michener LA. Mechanisms of rotator cuff
tendinopathy: Intrinsic, extrinsic, or both? Clin
Biomech. 2011;26(1):1-12. doi:10.1016/j.clinbiomec
h.2010.08.001
41. Sahrmann SA. Diagnosis by the physical
therapist-a prerequisite for treatment. A special
communication. Phys Ther. 1988;68(11):1703-1706. d
oi:10.1093/ptj/68.11.1703
 Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification
42. Spoto MM, Collins J. Physiotherapy diagnosis in
clinical practice: A survey of orthopaedic certified
specialists in the USA. Physiother Res Int.
2008;13(1):31-41. doi:10.1002/pri.390
43. Ludewig PM, Phadke V, Braman JP, Hassett DR,
Cieminski CJ, LaPrade RF. Motion of the shoulder
complex during multiplanar humeral elevation. J Bone
Joint Surg Am. 2009;91(2):378-389. doi:10.2106/jbj
s.g.01483
44. Rabin A, Chechik O, Dolkart O, Goldstein Y,
Maman E. A positive scapular assistance test is
equally present in various shoulder disorders but
more commonly found among patients with scapular
dyskinesis. Phys Ther Sport. 2018;34:129-135. doi:1
0.1016/j.ptsp.2018.09.008
45. Neumann DA, Camargo PR. Kinesiologic
considerations for targeting activation of
scapulothoracic muscles - part 1: serratus anterior.
Braz J Phys Ther. 2019;23(6):459-466. doi:10.1016/j.bj
pt.2019.01.008
46. Hardwick DH, Beebe JA, McDonnell MK, Lang CE.
A comparison of serratus anterior muscle activation
during a wall slide exercise and other traditional
exercises. J Orthop Sports Phys Ther.
2006;36(12):903-910. doi:10.2519/jospt.2006.2306
47. Kalkhoven JT, Watsford ML, Impellizzeri FM. A
conceptual model and detailed framework for stress-
related, strain-related, and overuse athletic injury. J
Sci Med Sport. 2020;23(8):726-734. doi:10.1016/j.jsam
s.2020.02.002
International Journal of Sports Physical Therapy
48. Bartlett R, Wheat J, Robins M. Is movement
variability important for sports biomechanists? Sports
Biomechanics. 2007;6(2):224-243. doi:10.1080/147631
40701322994
49. Wade MG, Smith TJ. Variability in human motor
and sport performance. In: Variability in Human
Performance. CRC Press; 2014:31-46. https://doi.org/1
0.1201/b17319-3
50. Harbourne RT, Stergiou N. Movement variability
and the use of nonlinear tools: principles to guide
physical therapist practice. Phys Ther.
2009;89(3):267-282. doi:10.2522/ptj.20080130
51. Pieters L, Lewis J, Kuppens K, et al. An Update of
Systematic Reviews Examining the Effectiveness of
Conservative Physical Therapy Interventions for
Subacromial Shoulder Pain. J Orthop Sports Phys Ther.
2020;50(3):131-141. doi:10.2519/jospt.2020.8498
52. Ludewig PM, Borstad JD. Effects of a home
exercise programme on shoulder pain and functional
status in construction workers. Occup Environ Med.
2003;60(11):841-849. doi:10.1136/oem.60.11.841
53. Lentz TA, Beneciuk JM, Bialosky JE, et al.
Development of a Yellow Flag Assessment Tool for
Orthopaedic Physical Therapists: Results From the
Optimal Screening for Prediction of Referral and
Outcome (OSPRO) Cohort. J Orthop Sports Phys Ther.
2016;46(5):327-343. doi:10.2519/jospt.2016.6487
 Changing our Diagnostic Paradigm Part II: Movement System Diagnostic Classification

APPENDIX A i. Thoracic posture/scoliosis

ii. Cervical posture/ROM
Proposed elements of a basic diagnostic process for atrau- iii. Shoulder complex initial alignment
matic shoulder pain: iv. Bilateral shoulder flexion with and without re-
sistance, repeated movements
1. Subjective key questions
v. Bilateral shoulder abduction with and without
a. What is the patient’s chief complaint?
resistance, repeated movements
i. Pain (constant or with movement)
vi. “Problem movement”/hand behind back etc.
ii. Mobility deficit
vii. Symptom relief tests (scapular assistance test
iii. Stability deficit
etc.)
iv. Weakness with or without pain, mobility or sta-
b. Seated follow up exam
bility deficits
i. Cervical symptom provocation/relief tests as
b. What is the level of condition irritability (provoca-
warranted
tion required, severity, pain persistence)?
ii. Shoulder mobility/stability tests (sulcus/AP load
c. What type of symptoms are present (pain, numb-
and shift)
ness, tingling, weakness, stiffness, etc.)?
iii. Symptom provocation/strength tests as war-
d. What is the location of the symptoms (gleno-
ranted
humeral joint pain rarely radiates past the elbow)?
iv. Select special tests
e. Mechanism of “injury” – specific injury, cumulative
c. Supine/prone follow-up exam
trauma, insidious onset?
i. Select length/strength/stability/nerve entrap-
f. What if any movements exacerbate/relieve symp-
ment tests as warranted
toms?
ii. Select special tests (e.g. apprehension, labral
g. Demographics, confounding factors (e.g. smoking)?
tests)
h. History/co-morbid conditions (e.g. diabetes)?
iii. Shoulder internal/external rotation in 90 de-
i. Red flags?
grees abduction, active and passive
j. Yellow flags (e.g. pain catastrophizing)53
3. Assessment and Movement System Diagnostic Label
2. Objective
a. Focused posture/movement exam

International Journal of Sports Physical Therapy